N A T I O N A L I N S T I T U T E S O F H E A L T HN A T I O N A L H E A R T , L U N G , A N D B L O O D I N S T I T U T E...
ACKNOWLEDGMENTS:The Working Group wishes to acknowledgethe additional input to the Practical Guide fromthe following indiv...
The PracticalGuideIdentification,Evaluation,and Treatmentof Overweight andObesity in AdultsNational Institutes of HealthNa...
NHLBI Obesity Education InitiativeExpert Panel on the Identification,Evaluation, and Treatment ofOverweight and Obesity in...
iiiForeword .................................................................................................................
ivIntroduction to the Appendices ............................................................................................
vIn June 1998, the Clinical Guidelines on theIdentification, Evaluation, and Treatment ofOverweight and Obesity in Adults:...
viOverweight and obesity, serious and growing health problems, are not receivingthe attention they deserve from primary ca...
vii23Measure height and weight so that you canestimate your patient’s BMI from the tablein Appendix A.Measure waist circum...
1Successful treatment …A lifelong effort.Treatment of an overweight orobese person incorporates a two-step process: assess...
2subsequent mortality; these willrequire aggressive management.Other conditions associated withobesity are less lethal but...
3lower than 800 kcal/day have beenfound to be no more effective thanlow-calorie diets in producingweight loss. They should...
4should be considered. Pharmaco-therapy is currently limited to thosepatients who have a BMI ≥ 30, orthose who have a BMI ...
5Obesity is a complex,multifactorial diseasethat develops fromthe interactionbetween genotypeand the environment. Our unde...
650403020100Men WomenPercentPrevalenceMen Women(BMI 25–29.9) (BMI ≥ 30)NHES I (1960-62)NHANES I (1971-74)NHANES II (1976-8...
7Although there is agreement about the health risks ofoverweight and obesity, there is less agreement abouttheir managemen...
8Although accurate methods toassess body fat exist, themeasurement of body fat bythese techniques is expensive and isoften...
9It should be noted that the risk lev-els for disease depicted in Table 2are relative risks; in other words,they are relat...
10ence are useful predictors ofchanges in cardiovascular disease(CVD) risk factors.27Men are atincreased relative risk if ...
11Assessment of the patient’s riskstatus includes the determina-tion of the following: thedegree of overweight or obesityu...
12their complications, and stressincontinence. Although obesepatients are at increased risk forgallstones, the risk of thi...
13Panel II [ATP II29] of theNational Cholesterol EducationProgram and the Sixth Report ofthe Joint National Committee onth...
Evaluation andTreatment StrategyWhen health care practitioners encounter patients in the clinical setting,opportunities ex...
16Treatment Algorithm*YesYesNoPatient encounter56Hx of ≥ 25 BMI?BMI measured inpast 2 years?BMI ≥ 25 OR waistcircumference...
17Does patient wantto lose weight?Progressbeing made/goalachieved?YesYesYes NoNoNoClinician and patientdevise goals andtre...
18Patient encounterAny interaction between ahealth care practitioner (generallya physician, nurse practitioner, orphysicia...
19Clinician and patientdevise goalsThe decision to lose weight mustbe made jointly between theclinician and patient. Patie...
Assess reasons for failureto lose weightIf a patient fails to achieve the rec-ommended 10-percent reduction inbody weight ...
21Ready or Not:Predicting Weight LossPredicting a patient’s readinessfor weight loss and identifyingpotential variables as...
22Clinical experience suggests thathealth care practitioners brieflyconsider the following issues whenassessing an obese i...
23The initial goal of weight losstherapy for overweightpatients is a reduction inbody weight of about 10 percent. Ifthis t...
24decrease calories and/or increasephysical activity. Many studies showthat rapid weight reduction is almostalways followe...
25Weight Management TechniquesEffective weight controlinvolves multiple tech-niques and strategiesincluding dietary therap...
26In the majority of overweight andobese patients, adjustment of thediet will be required to reducecaloric intake. Dietary...
27Table 4Low-Calorie Step I DietNutrient Recommended IntakeCalories1Approximately 500 to 1,000 kcal/day reduction from usu...
28Physical activity should be anintegral part of weight losstherapy and weight mainte-nance. Initially, moderate levels of...
29100 to 200 kcal/day of physicalactivity can be expended. Caloricexpenditure will vary depending onthe individual’s body ...
30physical activity is roughly equiv-alent to physical activity that usesapproximately 150 calories ofenergy per day, or 1...
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight
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Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight

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Practical guide to evaluation and treatment of obesity overweight for physicians help your patients lose weight

  1. 1. N A T I O N A L I N S T I T U T E S O F H E A L T HN A T I O N A L H E A R T , L U N G , A N D B L O O D I N S T I T U T EN A T I O N A L I N S T I T U T E S O F H E A L T HN A T I O N A L H E A R T , L U N G , A N D B L O O D I N S T I T U T EN O R T H A M E R I C A N A S S O C I A T I O N F O R T H E S T U D Y O F O B E S I T YThe PracticalGuideIdentification,Evaluation,and Treatmentof Overweight andObesity in AdultsNHLBI Obesity Education Initiative
  2. 2. ACKNOWLEDGMENTS:The Working Group wishes to acknowledgethe additional input to the Practical Guide fromthe following individuals: Dr. Thomas Wadden,University of Pennsylvania; Dr. Walter Pories,East Carolina University; Dr. Steven Blair,Cooper Institute for Aerobics Research; andDr. Van S. Hubbard, National Institute ofDiabetes and Digestive and Kidney Diseases.
  3. 3. The PracticalGuideIdentification,Evaluation,and Treatmentof Overweight andObesity in AdultsNational Institutes of HealthNational Heart, Lung, and Blood InstituteNIH Publication Number 00-4084October 2000NHLBI Obesity Education InitiativeNorth American Association for the Study of Obesity
  4. 4. NHLBI Obesity Education InitiativeExpert Panel on the Identification,Evaluation, and Treatment ofOverweight and Obesity in Adults.F.Xavier Pi-Sunyer, M.D., M.P.H.Columbia University Collegeof Physicians and SurgeonsChair of the PanelMEMBERSDiane M. Becker, Sc.D., M.P.H.The Johns Hopkins UniversityClaude Bouchard, Ph.D.Laval UniversityRichard A. Carleton, M.D.Brown University School of MedicineGraham A. Colditz, M.D., Dr.P.H.Harvard Medical SchoolWilliam H. Dietz, M.D., Ph.D.National Center for Chronic DiseasePrevention and Health PromotionCenters for Disease Control and PreventionJohn P. Foreyt, Ph.D.Baylor College of MedicineRobert J. Garrison, Ph.D.University of Tennessee, MemphisScott M. Grundy, M.D., Ph.D.University of Texas SouthwesternMedical Center at DallasBarbara C. Hansen, Ph.D.University of Maryland School of MedicineMillicent Higgins, M.D.University of MichiganJames O. Hill, Ph.D.University of ColoradoHealth Sciences CenterBarbara V. Howard, Ph.D.Medlantic Research InstituteRobert J. Kuczmarski, Dr.P.H., R.D.National Center for Health StatisticsCenters for Disease Control and PreventionShiriki Kumanyika, Ph.D., R.D., M.P.H.The University of PennsylvaniaR. Dee Legako, M.D.Prime Care Canyon ParkFamily Physicians, Inc.T. Elaine Prewitt, Dr.P.H., R.D.Loyola University Medical CenterAlbert P. Rocchini, M.D.University of Michigan Medical CenterPhilip L Smith, M.D.The Johns Hopkins Asthmaand Allergy CenterLinda G. Snetselaar, Ph.D., R.D.University of IowaJames R. Sowers, M.D.Wayne State University School of MedicineUniversity Health CenterMichael Weintraub, M.D.Food and Drug AdministrationDavid F. Williamson, Ph.D., M.S.Centers for Disease Control and PreventionG. Terence Wilson, Ph.D.Rutgers Eating Disorders ClinicEX-OFFICIO MEMBERSClarice D. Brown, M.S.Coda Research Inc.Karen A. Donato, M.S., R.D.*Executive Director of the PanelCoordinator, NHLBI ObesityEducation InitiativeNational Heart, Lung, and Blood InstituteNational Institutes of HealthNancy Ernst, Ph.D., R.D.*National Heart, Lung, and Blood InstituteNational Institutes of HealthD. Robin Hill, Ph.D.*National Heart, Lung, and Blood InstituteNational Institutes of HealthMichael J. Horan, M.D., Sc.M.*National Heart, Lung, and Blood InstituteNational Institutes of HealthVan S. Hubbard, M.D., Ph.D.National Institute of Diabetes andDigestive and Kidney DiseasesJames P. Kiley, Ph.D.*National Heart, Lung, and Blood InstituteNational Institutes of HealthEva Obarzanek, Ph.D., R.D., M.P.H.*National Heart, Lung, and Blood InstituteNational Institutes of Health*NHLBI Obesity Initiative Task Force MemberCONSULTANTDavid Schriger, M.D., M.P.H., F.A.C.E.P.University of CaliforniaLos Angeles School of MedicineSAN ANTONIO COCHRANE CENTERElaine Chiquette, Pharm.D.Cynthia Mulrow, M.D., M.Sc.V.A. Cochrane Center at San AntonioAudie L. Murphy MemorialVeterans HospitalSTAFFAdrienne Blount, Maureen Harris, M.S., R.D.,Anna Hodgson, M.A., Pat Moriarty, M.Ed.,R.D., R.O.W. Sciences, Inc.North American Association for theStudy of Obesity Practical GuideDevelopment CommitteeLouis J. Aronne, M.D., F.A.C.P.Cornell University, ChairMEMBERSCharles Billington, M.D.University of MinnesotaGeorge Blackburn, M.D., Ph.D.Harvard UniversityKaren A. Donato, M.S., R. D.NHLBI Obesity Education InitiativeNational Heart, Lung, andBlood InstituteNational Institutes of HealthArthur Frank, M.D.George Washington UniversitySusan Fried, Ph.D.Rutgers UniversityPatrick Mahlen ONeil, Ph.D.Medical University of South CarolinaHenry Buchwald, M.D.University of MinnesotaGeorge Cowan, M.D.University of TennesseeCollege of MedicineRobert Brolin, M.D.UMDNJ-Robert Wood JohnsonMedical SchoolEX-OFFICIO MEMBERSJames O. Hill, Ph.D.University of ColoradoHealth Sciences CenterEdward Bernstein, M.P.H.North American Associationfor the Study of Obesity
  5. 5. iiiForeword ......................................................................................................................................vHow To Use This Guide..............................................................................................................viExecutive Summary ....................................................................................................................1Assessment..........................................................................................................................1Body Mass Index...........................................................................................................1Waist Circumference.....................................................................................................1Risk Factors or Comorbidities.......................................................................................1Readiness To Lose Weight............................................................................................2Management.........................................................................................................................2Weight Loss ..................................................................................................................2Prevention of Weight Gain ............................................................................................2Therapies..............................................................................................................................2Dietary Therapy.............................................................................................................2Physical Activity ............................................................................................................3Behavior Therapy ..........................................................................................................3Pharmacotherapy..........................................................................................................3Weight Loss Surgery.....................................................................................................4Special Situations.................................................................................................................4Introduction..................................................................................................................................5The Problem of Overweight and Obesity .............................................................................5Treatment Guidelines..................................................................................................................7Assessment and Classification of Overweight and Obesity.................................................8Assessment of Risk Status ................................................................................................11Evaluation and Treatment Strategy ....................................................................................15Ready or Not: Predicting Weight Loss ...............................................................................21Management of Overweight and Obesity...........................................................................23Weight Management Techniques.............................................................................................25Dietary Therapy..................................................................................................................26Physical Activity..................................................................................................................28Behavior Therapy ...............................................................................................................30Making the Most of the Patient Visit............................................................................30Pharmacotherapy ...............................................................................................................35Weight Loss Surgery..........................................................................................................38Weight Reduction After Age 65 ...............................................................................................41References .................................................................................................................................42Table of Contents
  6. 6. ivIntroduction to the Appendices ...............................................................................................45Appendix A. Body Mass Index Table..................................................................................46Appendix B. Shopping—What to Look For ........................................................................47Appendix C. Low Calorie, Lower Fat Alternatives..............................................................49Appendix D. Sample Reduced Calorie Menus...................................................................51Appendix E. Food Exchange List.......................................................................................57Appendix F. Food Preparation—What to Do .....................................................................59Appendix G. Dining Out—How To Choose.........................................................................60Appendix H. Guide to Physical Activity ..............................................................................62Appendix I. Guide to Behavior Change ............................................................................68Appendix J. Weight and Goal Record ...............................................................................71Appendix K. Weekly Food and Activity Diary.....................................................................74Appendix L. Additional Resources.....................................................................................75List of TablesTable 1. Classifications for BMI.....................................................................................1Table 2. Classification of Overweight and Obesity by BMI, Waist Circumference,and Associated Disease Risk........................................................................10Table 3. A Guide to Selecting Treatment.....................................................................25Table 4. Low-Calorie Step I Diet .................................................................................27Table 5. Examples of Moderate Amounts of Physical Activity ....................................29Table 6. Weight Loss Drugs ........................................................................................36List of FiguresFigure 1. Age-Adjusted Prevalence of Overweight (BMI 25–29.9) andObesity (BMI ≥ 30) ..........................................................................................6Figure 2. NHANES III Age-Adjusted Prevalence of High Blood Pressure (HBP),High Total Blood Cholesterol (TBC), and Low-HDL by Two BMI Categories ..6Figure 3. Measuring-Tape Position for Waist (Abdominal) Circumference in Adults ......9Figure 4. Treatment Algorithm ......................................................................................16Figure 5. Surgical Procedures in Current Use..............................................................38
  7. 7. vIn June 1998, the Clinical Guidelines on theIdentification, Evaluation, and Treatment ofOverweight and Obesity in Adults: EvidenceReport was released by the National Heart, Lung,and Blood Institute’s (NHLBI) Obesity EducationInitiative in cooperation with the National Instituteof Diabetes and Digestive and Kidney Diseases(NIDDK). The impetus behind the clinical practiceguidelines was the increasing prevalence of over-weight and obesity in the United States and the needto alert practitioners to accompanying health risks.The Expert Panel that developed the guidelinesconsisted of 24 experts, 8 ex-officio members, and aconsultant methodologist representing the fields ofprimary care, clinical nutrition, exercise physiology,psychology, physiology, and pulmonary disease.The guidelines were endorsed by representativesof the Coordinating Committees of the NationalCholesterol Education Program and the NationalHigh Blood Pressure Education Program, the NorthAmerican Association for the Study of Obesity, andthe NIDDK National Task Force on the Preventionand Treatment of Obesity.This Practical Guide to the Identification, Evaluation,and Treatment of Overweight and Obesity in Adults islargely based on the evidence report prepared by theExpert Panel and describes how health care practition-ers can provide their patients with the direction andsupport needed to effectively lose weight and keep itoff. It provides the basic tools needed to appropriatelyassess and manage overweight and obesity.The guide includes practical information on dietarytherapy, physical activity, and behavior therapy, whilealso providing guidance on the appropriate use ofpharmacotherapy and surgery as treatment options.The Guide was prepared by a working group con-vened by the North American Association for theStudy of Obesity and the National Heart, Lung, andBlood Institute. Three members of the AmericanSociety for Bariatric Surgery also participated inthe working group. Members of the Expert Panel,especially the Panel Chairman, assisted in the reviewand development of the final product. Special thanksare also due to the 50 representatives of the variousdisciplines in primary care and others who reviewedthe preprint of the document and provided theworking group with excellent feedback.The Practical Guide will be distributed to primarycare physicians, nurses, registered dietitians, andnutritionists as well as to other interested health carepractitioners. It is our hope that the tools provided herehelp to complement the skills needed to effectivelymanage the millions of overweight and obese individ-uals who are attempting to manage their weight.David York, Ph.D. Claude Lenfant,M.D.President DirectorNorth American Association National Heart, Lung,for the Study of Obesity and Blood InstituteNational Institutesof HealthForeword
  8. 8. viOverweight and obesity, serious and growing health problems, are not receivingthe attention they deserve from primary care practitioners. Among the reasonscited for not treating overweight and obesity is the lack of authoritative informationto guide treatment. This Practical Guide to the Identification, Evaluation, andTreatment of Overweight and Obesity in Adults was developed cooperatively bythe North American Association for the Study of Obesity (NAASO) and the National Heart,Lung, and Blood Institute (NHLBI). It is based on the Clinical Guidelines on the Identification,Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report developed bythe NHLBI Expert Panel and released in June 1998. The Expert Panel used an evidence-basedmethodology to develop key recommendations for assessing and treating overweight and obesepatients. The goal of the Practical Guide is to provide you with the tools you need to effectivelymanage your overweight and obese adult patients in an efficient manner.The Guide has been developed to help you easily access all of the information you need.The Executive Summary contains the essential information in an abbreviated form.The Treatment Guidelines section offers details on assessment and management of patientsand features the Expert Panel’s Treatment Algorithm, which provides a step-by-step approachto learning how to manage patients.The Appendix contains practical tools related to diet, physical activity, and behavioralmodification needed to educate and inform your patients. The Appendix has been formattedso that you can copy it and explain it to your patients.Managing overweight and obese patients requires a variety of skills. Physicians play a key role inevaluating and treating such patients. Also important are the special skills of nutritionists, registereddietitians, psychologists, and exercise physiologists. Each health care practitioner can help patientslearn to make some of the changes they may need to make over the long term. Organizing a “team”of various health care practitioners is one way of meeting the needs of patients. If that approach isnot possible, patients can be referred to other specialists required for their care.To get started, just follow the Ten Step approach.How to Use This Guide
  9. 9. vii23Measure height and weight so that you canestimate your patient’s BMI from the tablein Appendix A.Measure waist circumferenceas described on page 9.Assess comorbidities as described onpages 11–12 in the section on“Assessment of Risk Status.”Should your patient be treated? Take theinformation you have gathered above and useFigure 4, the Treatment Algorithm, on pages16–17 to decide. Pay particular attention toBox 7 and the accompanying explanatorytext. If the answer is “yes” to treatment,decide which treatment is best using Table 3on page 25.Is the patient ready and motivated to loseweight? Evaluation of readiness shouldinclude the following: (1) reasons andmotivation for weight loss, (2) previousattempts at weight loss, (3) support expectedfrom family and friends, (4) understanding ofrisks and benefits, (5) attitudes towardphysical activity, (6) time availability,and (7) potential barriers to the patient’sadoption of change.Which diet should you recommend?In general, diets containing 1,000 to 1,200kcal/day should be selected for most women;a diet between 1,200 kcal/day and 1,600kcal/day should be chosen for men and maybe appropriate for women who weigh 165pounds or more, or who exercise regularly. Ifthe patient can stick with the 1,600 kcal/daydiet but does not lose weight you may want totry the 1,200 kcal/day diet. If a patient oneither diet is hungry, you may want toincrease the calories by 100 to 200 per day.Included in Appendix D are samples of botha 1,200 and 1,600 calorie diet.Discuss a physical activity goal with thepatient using the Guide to Physical Activity(see Appendix H). Emphasize the importanceof physical activity for weight maintenanceand risk reduction.Review the Weekly Food and ActivityDiary (see Appendix K) with the patient.Remind the patient that record-keeping hasbeen shown to be one of the most successfulbehavioral techniques for weight loss andmaintenance. Write down the diet, physicalactivity, and behavioral goals you have agreedon at the bottom.Give the patient copies of the dietaryinformation (see Appendices B–G),the Guide to Physical Activity (seeAppendix H), the Guide to BehaviorChange (see Appendix I), and the WeeklyFood and Activity Diary (see Appendix K).Enter the patient’s information and thegoals you have agreed on in the Weight andGoal Record (see Appendix J). It is importantto keep track of the goals you have set andto ask the patient about them at the next visitto maximize compliance. Have the patientschedule an appointment to see you or yourstaff for followup in 2 to 4 weeks.457896101Ten Steps to Treating Overweight and Obesity in the Primary Care Setting
  10. 10. 1Successful treatment …A lifelong effort.Treatment of an overweight orobese person incorporates a two-step process: assessment andmanagement. Assessment includesdetermination of the degree ofobesity and overall health status.Management involves not onlyweight loss and maintenance ofbody weight but also measures tocontrol other risk factors. Obesityis a chronic disease; patient andpractitioner must understand thatsuccessful treatment requires alifelong effort. Convincing evidencesupports the benefit of weight lossfor reducing blood pressure,lowering blood glucose, andimproving dyslipidemias.AssessmentBody Mass IndexAssessment of a patient shouldinclude the evaluation of body massindex (BMI), waist circumference,and overall medical risk. To esti-mate BMI, multiply the individual’sweight (in pounds) by 703, thendivide by the height (in inches)squared. This approximates BMIin kilograms per meter squared(kg/m2). There is evidence to sup-port the use of BMI in risk assess-ment since it provides a more accu-rate measure of total body fat com-pared with the assessment of bodyweight alone. Neither bioelectricimpedance nor height-weight tablesprovide an advantage over BMIin the clinical management ofall adult patients, regardless ofgender. Clinical judgment must beemployed when evaluating verymuscular patients because BMI mayoverestimate the degree of fatness inthese patients. The recommendedclassifications for BMI, adoptedby the Expert Panel on theIdentification, Evaluation, andTreatment of Overweight andObesity in Adults and endorsed byleading organizations of healthprofessionals, are shown in Table 1.Waist CircumferenceExcess abdominal fat is an impor-tant, independent risk factor for dis-ease. The evaluation of waist cir-cumference to assess the risks asso-ciated with obesity or overweight issupported by research. The measure-ment of waist-to-hip ratio providesno advantage over waist circumfer-ence alone. Waist circumferencemeasurement is particularly useful inpatients who are categorized as nor-mal or overweight. It is not neces-sary to measure waist circumferencein individuals with BMIs ≥ 35 kg/m2since it adds little to the predictivepower of the disease risk classifica-tion of BMI. Men who have waistcircumferences greater than 40 inch-es, and women who have waist cir-cumferences greater than 35 inches,are at higher risk of diabetes, dys-lipidemia, hypertension, and cardio-vascular disease because of excessabdominal fat. Individuals withwaist circumferences greater thanthese values should be consideredone risk category above that definedby their BMI. The relationshipbetween BMI and waist circumfer-ence for defining risk is shown inTable 2 on page 10.Risk Factors or ComorbiditiesOverall risk must take into accountthe potential presence of other riskfactors. Some diseases or riskfactors associated with obesity placepatients at a high absolute risk forExecutive SummaryBMIUnderweight <18.5 kg/m2Normal weight 18.5–24.9 kg/m2Overweight 25–29.9 kg/m2Obesity (Class 1) 30–34.9 kg/m2Obesity (Class 2) 35–39.9 kg/m2Extreme obesity (Class 3) ≥40 kg/m2Classifications for BMITable 1
  11. 11. 2subsequent mortality; these willrequire aggressive management.Other conditions associated withobesity are less lethal but stillrequire treatment.Those diseases or conditions thatdenote high absolute risk areestablished coronary heart disease,other atherosclerotic diseases,type 2 diabetes, and sleep apnea.Osteoarthritis, gallstones, stressincontinence, and gynecologicalabnormalities such as amenorrheaand menorrhagia increase risk butare not generally life-threatening.Three or more of the followingrisk factors also confer highabsolute risk: hypertension, ciga-rette smoking, high low-densitylipoprotein cholesterol, lowhigh-density lipoprotein choles-terol, impaired fasting glucose,family history of early cardiovas-cular disease, and age (male ≥ 45years, female ≥ 55 years). Theintegrated approach to assessmentand management is portrayed inFigure 4 on pages 16–17(Treatment Algorithm).Readiness To Lose WeightThe decision to attempt weight-losstreatment should also consider thepatient’s readiness to make the nec-essary lifestyle changes. Evaluationof readiness should include thefollowing:Reasons and motivationfor weight lossPrevious attempts at weight lossSupport expected from familyand friendsUnderstanding of risksand benefitsAttitudes toward physicalactivityTime availabilityPotential barriers, includingfinancial limitations, to thepatient’s adoption of changeManagementWeight LossIndividuals at lesser risk should becounseled about effective lifestylechanges to prevent any furtherweight gain. Goals of therapy are toreduce body weight and maintain alower body weight for the longterm; the prevention of furtherweight gain is the minimum goal.An initial weight loss of 10 percentof body weight achieved over 6months is a recommended target.The rate of weight loss should be 1to 2 pounds each week. Greaterrates of weight loss do not achievebetter long-term results. After thefirst 6 months of weight loss thera-py, the priority should be weightmaintenance achieved through com-bined changes in diet, physical activi-ty, and behavior. Further weight losscan be considered after a period ofweight maintenance.Prevention of Weight GainIn some patients, weight loss ora reduction in body fat is notachievable. A goal for thesepatients should be the preventionof further weight gain. Preventionof weight gain is also an appropri-ate goal for people with a BMIof 25 to 29.9 who are not other-wise at high risk.TherapiesA combination of diet modification,increased physical activity, andbehavior therapy can be effective.Dietary TherapyCaloric intake should be reducedby 500 to 1,000 calories per day(kcal/day) from the current level.Most overweight and obese peopleshould adopt long-term nutritionaladjustments to reduce caloric intake.Dietary therapy includes instructionsfor modifying diets to achieve thisgoal. Moderate caloric reductionis the goal for the majority of cases;however, diets with greater caloricdeficits are used during activeweight loss. The diet should be lowin calories, but it should not be toolow (less than 800 kcal/day). DietsWeight loss therapy isrecommended for patientswith a BMI ≥ 30 and for patientswith a BMI between 25 and 29.9OR a high-risk waistcircumference, and twoor more risk factors.
  12. 12. 3lower than 800 kcal/day have beenfound to be no more effective thanlow-calorie diets in producingweight loss. They should not beused routinely, especially not byproviders untrained in their use.In general, diets containing1,000 to 1,200 kcal/day should beselected for most women; a dietbetween 1,200 kcal/day and 1,600kcal/day should be chosen formen and may be appropriate forwomen who weigh 165 poundsor more, or who exercise.Long-term changes in food choicesare more likely to be successfulwhen the patient’s preferences aretaken into account and when thepatient is educated about food com-position, labeling, preparation, andportion size. Although dietary fat isa rich source of calories, reducingdietary fat without reducing calorieswill not produce weight loss.Frequent contact with practitionersduring the period of diet adjustmentis likely to improve compliance.Physical ActivityPhysical activity has directand indirect benefits.Increased physical activity isimportant in efforts to lose weightbecause it increases energy expen-diture and plays an integral role inweight maintenance. Physical activ-ity also reduces the risk of heartdisease more than that achieved byweight loss alone. In addition,increased physical activity may helpreduce body fat and prevent thedecrease in muscle mass oftenfound during weight loss. For theobese patient, activity should gener-ally be increased slowly, with caretaken to avoid injury. A wide vari-ety of activities and/or householdchores, including walking, dancing,gardening, and team or individualsports, may help satisfy this goal.All adults should set a long-termgoal to accumulate at least 30 min-utes or more of moderate-intensityphysical activity on most, andpreferably all, days of the week.Behavior TherapyIncluding behavioral therapyhelps with compliance.Behavior therapy is a useful adjunctto planned adjustments in foodintake and physical activity.Specific behavioral strategiesinclude the following: self-monitor-ing, stress management, stimuluscontrol, problem-solving, contin-gency management, cognitiverestructuring, and social support.Behavioral therapies may beemployed to promote adoption ofdiet and activity adjustments; thesewill be useful for a combinedapproach to therapy. Strong evi-dence supports the recommendationthat weight loss and weight mainte-nance programs should employ acombination of low-calorie diets,increased physical activity, andbehavior therapy.PharmacotherapyPharmacotherapy may be helpfulfor eligible high-risk patients.Pharmacotherapy, approved by theFDA for long-term treatment, canbe a helpful adjunct for the treat-ment of obesity in some patients.These drugs should be used only inthe context of a treatment programthat includes the elements describedpreviously—diet, physical activitychanges, and behavior therapy.If lifestyle changes do not promoteweight loss after 6 months, drugsReductions of 500to 1,000 kcal/daywill produce a recom-mended weight loss of1 to 2 pounds per week.1,000 to 1,200 kcal/dayfor most women1,200 to 1,600 kcal/dayshould be chosen for men
  13. 13. 4should be considered. Pharmaco-therapy is currently limited to thosepatients who have a BMI ≥ 30, orthose who have a BMI ≥ 27 if con-comitant obesity-related risk factorsor diseases exist. However, not allpatients respond to a given drug.If a patient has not lost 4.4 pounds(2 kg) after 4 weeks, it is not likelythat this patient will benefit fromthe drug. Currently, sibutramine andorlistat are approved by the FDAfor long-term use in weight loss.Sibutramine is an appetite suppres-sant that is proposed to work vianorepinephrine and serotonergicmechanisms in the brain. Orlistatinhibits fat absorption from theintestine. Both of these drugs haveside effects. Sibutramine mayincrease blood pressure and inducetachycardia; orlistat may reduce theabsorption of fat-soluble vitaminsand nutrients. The decision to add adrug to an obesity treatment pro-gram should be made after consid-eration of all potential risks andbenefits and only after all behav-ioral options have been exhausted.Weight Loss SurgerySurgery is an option for patientswith extreme obesity.Weight loss surgery providesmedically significant sustainedweight loss for more than 5 yearsin most patients. Although thereare risks associated with surgery,it is not yet known whether theserisks are greater in the long termthan those of any other form oftreatment. Surgery is an optionfor well-informed and motivatedpatients who have clinically severeobesity (BMI ≥ 40) or a BMI ≥ 35and serious comorbid conditions.(The term “clinically severeobesity” is preferred to the oncecommonly used term “morbidobesity.”) Surgical patients shouldbe monitored for complications andlifestyle adjustments throughouttheir lives.Special SituationsInvolve other healthprofessionals when possible,especially for special situations.Although research regardingobesity treatment in older peopleis not abundant, age should notpreclude therapy for obesity. Inpeople who smoke, the risk ofweight gain is often a barrier tosmoking cessation. In thesepatients, cessation of smokingshould be encouraged first, andweight loss therapy should bean additional goal.A weight loss and maintenanceprogram can be conducted by apractitioner without specializationin weight loss so long as thatperson has the requisite interestand knowledge. However, avariety of practitioners withspecial skills are available andmay be enlisted to assist in thedevelopment of a program.clinically severe obesity(BMI ≥ 40) or a BMI ≥ 35and serious comorbidconditions may warrantsurgery for weight loss.A combination of diet modification,increased physical activity, andbehavior therapy can be effective.Effective Therapies
  14. 14. 5Obesity is a complex,multifactorial diseasethat develops fromthe interactionbetween genotypeand the environment. Our under-standing of how and why obesityoccurs is incomplete; however, itinvolves the integration of social,behavioral, cultural, physiological,metabolic, and genetic factors.1Today, health care practitioners areencouraged to play a greater role inthe management of obesity. Manyphysicians are seeking guidance ineffective methods of treatment.This guide provides the basic toolsneeded to assess and manage over-weight and obesity in an office set-ting. A physician who is familiarwith the basic elements of these ser-vices can more successfully fulfillthe critical role of helping thepatient improve health by identify-ing the problem and coordinatingother resources within the commu-nity to assist the patient.Effective management of overweightand obesity can be delivered by avariety of health care professionalswith diverse skills working as ateam. For example, physicianinvolvement is needed for the initialassessment of risk and the prescrip-tion of appropriate treatment pro-grams that may include pharma-cotherapy, surgery, and the medicalmanagement of the comorbidities ofobesity. In addition, physicians canand should engage the assistance ofother professionals. This guide pro-vides the basic tools needed toassess and manage overweight andobesity for a variety of health profes-sionals, including nutritionists, regis-tered dietitians, exercise physiolo-gists, nurses, and psychologists.These professionals offer expertisein dietary counseling, physical activ-ity, and behavior changes and can beused for assessment, treatment, andfollow-up during weight loss andweight maintenance. The relation-ship between the practitioner andthese professionals can be a direct,formal one (as a “team”), or it maybe based on an indirect referral. Apositive, supportive attitude andencouragement from all profession-als are crucial to the continuing suc-cess of the patient.The Problem ofOverweight and ObesityAn estimated 97 million adults in theUnited States are overweight orobese.2These conditions substantial-ly increase the risk of morbidityfrom hypertension,3dyslipidemia,4type 2 diabetes,5,6,7,8coronary arterydisease,9stroke,10gallbladder dis-ease,11osteoarthritis,12and sleepapnea and respiratory problems,13aswell as cancers of the endometrium,breast, prostate, and colon.14Higherbody weights are also associatedwith an increase in mortality fromall causes.5Obese individuals mayalso suffer from social stigmatizationand discrimination. As a major causeof preventable death in the UnitedStates today,15overweight and obesitypose a major public health challenge.However, overweight and obesity arenot mutually exclusive, since obesepersons are also overweight. A BMIof 30 indicates an individual is about30 pounds overweight; it may beexemplified by a 221-pound personwho is 6 feet tall or a 186-pound indi-vidual who is 5 feet 6 inches tall. Thenumber of overweight and obese menand women has risen since 1960(Figure 1); in the last decade, the per-centage of adults, ages 20 years orolder, who are in these categories hasincreased to 54.9 percent.2Over-weight and obesity are especially evi-dent in some minority groups, aswell as in those with lower incomesand less education.16,17The presence of overweight and obe-sity in a patient is of medical con-cern for several reasons. It increasesthe risk for several diseases, particu-larly cardiovascular diseases (CVD)and diabetes mellitus.7,8Data fromNHANES III show that morbidityfor a number of health conditionsincreases as BMI increases in bothmen and women (Figure 2).IntroductionAccording to the Expert Panel,overweight is defined as a bodymass index (BMI) of 25 to29.9 kg/m2, and obesity isdefined as a BMI ≥ 30 kg/m2.
  15. 15. 650403020100Men WomenPercentPrevalenceMen Women(BMI 25–29.9) (BMI ≥ 30)NHES I (1960-62)NHANES I (1971-74)NHANES II (1976-80)NHANES III (1988-94)Source: CDC/NCHS. United States. 1960-94, Ages 20-74 years. For comparison across surveys, data for subjects ages 20to 74 years were age-adjusted by the direct method to the total U.S. population for 1980, using the age-adjusted categories20-29y, 30-39y, 40-49y, 50-59y, 60-69y, and 70-79y.<25 ≥3018.3HBP TBC HDL<25 ≥30 <25 ≥30BMI* Defined as mean systolic blood pressure > 140 mm Hg, mean diastolic blood pressure > 90 mm Hg,or currently taking antihypertensive medication.† Defined as > 240 mg/dl.‡ Defined as < 35 mg/dl in men and < 45 mg/dl in women.Source: Brown C et al. Body mass index and the prevalence of hypertension and dyslipidemia (in press).45403530252015105016.239.232.414.7 14.620.224.39.316.331.542.037.841.139.1 39.423.6 23.624.3 24.710.411.312.219.915.116.1 16.324.9Age-Adjusted Prevalence of Overweight (BMI 25–29.9) and Obesity (BMI ≥ 30)Figure 1NHANES III Age-Adjusted Prevalence of High Blood Pressure (HBP),* High TotalBlood Cholesterol (TBC),† and Low-HDL‡ by Two BMI CategoriesFigure 2MenWomen
  16. 16. 7Although there is agreement about the health risks ofoverweight and obesity, there is less agreement abouttheir management. Some have argued against treatingobesity because of the difficulty in maintaininglong-term weight loss, and because of the potentiallynegative consequences of weight cycling, a pattern frequently seenin obese individuals. Others argue that the potential hazards oftreatment do not outweigh the known hazards of being obese.The treatment guidelines provided are based on the most thoroughexamination of the scientific evidence reported to date on theeffectiveness of various treatment strategies available for weight lossand weight maintenance.Treatment of the overweight and obese patient is a two-step process:assessment and management.Assessment requires determination of the degree of obesityand the absolute risk status.Management includes the reduction of excess weight andmaintenance of this lower body weight, as well as the institutionof additional measures to control any associated risk factors.The aim of this guide is to provide useful advice on how toachieve weight reduction and how to maintain a lower body weight.Obesity is a chronic disease; the patient and the practitioner needto understand that successful treatment requires a lifelong effort.Treatment GuidelinesTailor Treatment to theNeeds of the PatientStandard treatment approachesfor overweight and obesity mustbe tailored to the needs of variouspatients or patient groups. Largeindividual variation exists withinany social or cultural group; fur-thermore, substantial overlapoccurs among subcultures withinthe larger society. There is, there-fore, no “cookbook” or standard-ized set of rules to optimize weightreduction with a given type ofpatient. However, obesity treatmentprograms that are culturallysensitive and incorporate apatient’s characteristics must dothe following:Adapt the setting and staffingfor the program.Understand how the obesitytreatment program integratesinto other aspects of the patient’shealth care and self-care.Expect and allow modifications toa program based on a patient’sresponse and preferences.
  17. 17. 8Although accurate methods toassess body fat exist, themeasurement of body fat bythese techniques is expensive and isoften not readily available to mostclinicians. Two surrogate measuresare important to assess body fat:Body mass index (BMI)Waist circumferenceBMI is recommended as a practicalapproach for assessing body fat inthe clinical setting. It provides amore accurate measure of totalbody fat compared with the assess-ment of body weight alone.18The typical body weight tables arebased on mortality outcomes, andthey do not necessarily predict mor-bidity. However, BMI has somelimitations. For example, BMI over-estimates body fat in persons whoare very muscular, and it can under-estimate body fat in persons whohave lost muscle mass (e.g., manyelderly). BMI is a direct calculationbased on height and weight, regard-less of gender.Waist circumference is the mostpractical tool a clinician can use toevaluate a patient’s abdominal fatbefore and during weight loss treat-ment (Figure 3). Computed tomog-raphy19and magnetic resonanceimaging20are both more accuratebut are impractical for routine clini-cal use. Fat located in the abdomi-nal region is associated with agreater health risk than peripheralfat (i.e., fat in the gluteal-femoralregion). Furthermore, abdominal fatappears to be an independent riskpredictor when BMI is not marked-ly increased.21,22Therefore, waist orabdominal circumference and BMIshould be measured not only for theinitial assessment of obesity butalso for monitoring the efficacyof the weight loss treatment forpatients with a BMI < 35.The primary classification of over-weight and obesity is based on theassessment of BMI. This classifica-tion, shown in Table 2, relates BMIto the risk of disease. It should benoted that the relationship betweenBMI and disease risk varies amongindividuals and among differentpopulations. Some individuals withmild obesity may have multiple riskfactors; others with more severeobesity may have fewer risk factors.Assessment and Classificationof Overweight and ObesityYou can calculate BMI as followsCalculation Directions and SampleHere is a shortcut method for calculatingBMI. (Example: for a person who is 5 feet5 inches tall weighing 180 lbs.)1. Multiply weight (in pounds) by 703180 x703 =126,5402. Multiply height (in inches) by height(in inches)65 x 65 =4,2253. Divide the answer in step 1 by theanswer in step 2 to get the BMI.126,540/4,225 = 29.9BMI = 29.9High-Risk WaistCircumferenceMen: > 40 in (> 102 cm)Women: > 35 in (> 88 cm)If pounds and inches are usedBMI =weight (pounds) x 703height squared (inches2)A BMI chart is provided in Appendix A.BMI =weight (kg)height squared (m2)A high waist circumference is associat-ed with an increased risk for type 2diabetes, dyslipidemia, hypertension,and CVD in patients with a BMIbetween 25 and 34.9 kg/m2.Disease Risks
  18. 18. 9It should be noted that the risk lev-els for disease depicted in Table 2are relative risks; in other words,they are relative to the risk atnormal body weight. There are norandomized, controlled trials thatsupport a specific classification sys-tem to establish the degree of dis-ease risk for patients during weightloss or weight maintenance.Although waist circumference andBMI are interrelated, waist circum-ference provides an independentprediction of risk over and abovethat of BMI. The waist circumfer-ence measurement is particularlyuseful in patients who are catego-rized as normal or overweight interms of BMI. For individuals witha BMI ≥ 35, waist circumferenceadds little to the predictive powerof the disease risk classification ofBMI. A high waist circumference isassociated with an increased risk fortype 2 diabetes, dyslipidemia,hypertension, and CVD inpatients with a BMI between25 and 34.9 kg/m.2,25In addition to measuring BMI,monitoring changes in waist cir-cumference over time may be help-ful; it can provide an estimate ofincreases or decreases in abdominalfat, even in the absence of changesin BMI. Furthermore, in obesepatients with metabolic complica-tions, changes in waist circumfer-To measure waistcircumference, locatethe upper hip bone andthe top of the right iliaccrest. Place a measur-ing tape in a horizontalplane around the abdo-men at the level of theiliac crest. Before read-ing the tape measure,ensure that the tape issnug, but does notcompress the skin, andis parallel to the floor.The measurement ismade at the end of anormal expiration.Waist Circumference MeasurementFigure 3Clinical judgment must beused in interpreting BMIin situations that may affect itsaccuracy as an indicator of totalbody fat. Examples of thesesituations include the presenceof edema, high muscularity, musclewasting, and individuals who arelimited in stature. The relationshipbetween BMI and body fat contentvaries somewhat with age, gender,and possibly ethnicity because ofdifferences in the composition oflean tissue, sitting height, andhydration state.23,24For example,older persons often have lostmuscle mass; thus, they havemore fat for a given BMI thanyounger persons. Women mayhave more body fat for a givenBMI than men, whereas patientswith clinical edema may have lessfat for a given BMI compared withthose without edema. Nevertheless,these circumstances do notmarkedly influence the validity ofBMI for classifying individuals intobroad categories of overweightand obesity in order to monitorthe weight status of individualsin clinical settings.23Measuring-Tape Position for Waist(Abdominal) Circumference in Adults
  19. 19. 10ence are useful predictors ofchanges in cardiovascular disease(CVD) risk factors.27Men are atincreased relative risk if they havea waist circumference greater than40 inches (102 cm); women are atan increased relative risk if theyhave a waist circumference greaterthan 35 inches (88 cm).There are ethnic and age-relateddifferences in body fat distributionthat modify the predictive validityof waist circumference as a surro-gate for abdominal fat.23In somepopulations (e.g., Asian Americansor persons of Asian descent), waistcircumference is a better indicatorof relative disease risk than BMI.28For older individuals, waist circum-ference assumes greater value forestimating risk of obesity-relateddiseases. Table 2 incorporates bothBMI and waist circumference inthe classification of overweight andobesity and provides an indicationof relative disease risk.Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risk*Disease Risk*BMI Obesity Class (Relative to Normal Weight(kg/m2) and Waist Circumference)Men ≤40 in (≤ 102 cm) > 40 in (> 102 cm)Women ≤ 35 in (≤ 88 cm) > 35 in (> 88 cm)Underweight < 18.5 - -Normal† 18.5–24.9 - -Overweight 25.0–29.9 Increased HighObesity 30.0–34.9 I High Very High35.0–39.9 II Very High Very HighExtreme Obesity ≥ 40 III Extremely High Extremely High* Disease risk for type 2 diabetes, hypertension, and CVD.† Increased waist circumference can also be a marker for increased risk even in persons of normal weight.Adapted from “Preventing and Managing the Global Epidemic of Obesity. Report of the World Health Organization Consultation of Obesity.” WHO, Geneva, June 1997.26Table 2
  20. 20. 11Assessment of the patient’s riskstatus includes the determina-tion of the following: thedegree of overweight or obesityusing BMI, the presence of abdomi-nal obesity using waist circumfer-ence, and the presence of concomi-tant CVD risk factors or comorbidi-ties. Some obesity-associated dis-eases and risk factors place patientsin a very high-risk category for sub-sequent mortality. Patients with thesediseases will require aggressive mod-ification of risk factors in addition tothe clinical management of the dis-ease. Other obesity-associated dis-eases are less lethal but still requireappropriate clinical therapy. Obesityalso has an aggravating influence onseveral cardiovascular risk factors.Identification of these risk factors isrequired to determine the intensityof a clinical intervention.1. Determine the relative riskstatus based on overweightand obesity parameters. Table2 defines relative risk categoriesaccording to BMI and waistcircumference. They relate tothe need to institute weight losstherapy, but they do not definethe required intensity of riskfactor modification. The latteris determined by the estimationof absolute risk based on thepresence of associated diseaseor risk factors.2. Identify patients at very highabsolute risk. Patients with thefollowing diseases have a veryhigh absolute risk that triggersthe need for intense risk-factormodification and managementof the diseases present:Established coronary heartdisease (CHD), including ahistory of myocardial infarction,angina pectoris (stable or unsta-ble), coronary artery surgery,or coronary artery procedures(e.g., angioplasty).Presence of other atheroscleroticdiseases, including peripheralarterial disease, abdominal aorticaneurysm, or symptomatic carotidartery disease.Type 2 diabetes (fasting plasmaglucose ≥ 126 mg/dL or 2-hpostprandial plasma glucose≥ 200 mg/dL) is a major risk fac-tor for CVD. Its presence aloneplaces a patient in the categoryof very high absolute risk.Sleep apnea. Symptoms andsigns include very loud snoringor cessation of breathing duringsleep, which is often followedby a loud clearing breath, thenbrief awakening.3. Identify other obesity-associ-ated diseases. Obese patientsare at increased risk for severalconditions that require detectionand appropriate managementbut that generally do not leadto widespread or life-threateningconsequences. These includegynecological abnormalities(e.g., menorrhagia, amenorrhea),osteoarthritis, gallstones andAssessment of Risk StatusMen are at increased relative risk for disease if they have a waistcircumference greater than 40 inches (102 cm); women are at anincreased relative risk if they have a waist circumference greaterthan 35 inches (88 cm).
  21. 21. 12their complications, and stressincontinence. Although obesepatients are at increased risk forgallstones, the risk of this dis-ease increases during periods ofrapid weight reduction.4. Identify cardiovascular riskfactors that impart a highabsolute risk. Patients can beclassified as being at highabsolute risk for obesity-relateddisorders if they have three ormore of the multiple risk factorslisted in the chart above. Thepresence of high absolute riskincreases the attention paid tocholesterol-lowering therapy29and blood pressure manage-ment.30Other risk factors deserve specialconsideration because their pres-ence heightens the need for weightreduction in obese persons.Physical inactivity imparts anincreased risk for both CVD andtype 2 diabetes.31Physical inac-tivity exacerbates the severity ofother risk factors, but it also hasbeen shown to be an indepen-dent risk factor for all-causemortality or CVD mortality.32,33Although physical inactivity isnot listed as a risk factor thatmodifies the intensity of therapyrequired for elevated cholesterolor blood pressure, increasedphysical activity is indicated formanagement of these conditions(please see the Adult TreatmentCigarette smoking.Hypertension(systolic blood pressureof ≥140 mm Hg or diastolicblood pressure ≥ 90 mm Hg)or current use of antihyperten-sive agents.High-risk low-densitylipoprotein (LDL) cholesterol(serum concentration≥ 160 mg/dL). A borderlinehigh-risk LDL-cholesterol(130 to 159 mg/dL) plus twoor more other risk factors alsoconfers high risk.Low high-density lipoprotein(HDL) cholesterol (serumconcentration < 35 mg/dL).Impaired fasting glucose(IFG) (fasting plasma glucosebetween 110 and 125 mg/dL).IFG is considered by manyauthorities to be an independentrisk factor for cardiovascular(macrovascular) disease, thusjustifying its inclusion amongrisk factors contributing tohigh absolute risk. IFG iswell established as a riskfactor for type 2 diabetes.Family history of prematureCHD (myocardial infarctionor sudden death experiencedby the father or other malefirst-degree relative at or before55 years of age, or experiencedby the mother or other femalefirst-degree relative at or before65 years of age).Age ≥ 45 years for men orage ≥ 55 years for women(or postmenopausal).Risk Factors
  22. 22. 13Panel II [ATP II29] of theNational Cholesterol EducationProgram and the Sixth Report ofthe Joint National Committee onthe Prevention, Detection,Evaluation, and Treatment ofHigh Blood Pressure [JNC VI30]).Increased physical activity isespecially needed in obesepatients because it promotesweight reduction as well asweight maintenance, andfavorably modifies obesity-associated risk factors.Conversely, the presence ofphysical inactivity in an obeseperson warrants intensifiedefforts to remove excess bodyweight because physical inac-tivity and obesity both heightendisease risks.Obesity is commonlyaccompanied by elevatedserum triglycerides.Triglyceride-rich lipoproteinsmay be directly atherogenic,and they are also the mostcommon manifestation ofthe atherogenic lipoproteinphenotype (high triglycerides,small LDL particles, and lowHDL-cholesterol levels).34Inthe presence of obesity, highserum triglycerides are common-ly associated with a clusteringof metabolic risk factors knownas the metabolic syndrome(atherogenic lipoproteinphenotype, hypertension,insulin resistance, glucoseintolerance, and prothromboticstates). Thus, in obese patients,elevated serum triglyceridesare a marker for increasedcardiovascular risk.Risk Factor ManagementManagement options of riskfactors for preventing CVD,diabetes, and other chronicdiseases are described in detail inother reports. For details on themanagement of serum cholesteroland other lipoprotein disorders,refer to the National CholesterolEducation Program’s SecondReport of the Expert Panel on theDetection, Evaluation, andTreatment of High BloodCholesterol in Adults (AdultTreatment Panel II, ATP II).29For thetreatment of hypertension, see theNational High Blood PressureEducation Program’s Sixth Reportof the Joint National Committee onthe Prevention, Detection,Evaluation, and Treatment of HighBlood Pressure (JNC VI).30See the Additional Resourceslist for ordering information fromthe National Heart, Lung, andBlood Institute (see Appendix L).Risk Factors and Weight LossIn overweight and obese personsweight loss is recommended toaccomplish the following:Lower elevated blood pressurein those with high blood pressure.Lower elevated blood glucoselevels in those with type2 diabetes.Lower elevated levels of totalcholesterol, LDL-cholesterol,and triglycerides, and raise lowlevels of HDL-cholesterol inthose with dyslipidemia.
  23. 23. Evaluation andTreatment StrategyWhen health care practitioners encounter patients in the clinical setting,opportunities exist for identifying overweight and obesity and theiraccompanying risk factors, as well as for initiating treatments forreducing weight, risk factors, and chronic diseases such as CVD and type 2 diabetes. Whenassessing a patient for treatment of overweight and obesity, consider the patient’s weight, waistcircumference, and presence of risk factors. The strategy for the evaluation and treatment ofoverweight patients is presented in Figure 4 (Treatment Algorithm). This algorithm appliesonly to the assessment for overweight and obesity; it does not reflect the overall evaluation ofother conditions and diseases performed by the clinician. Therapeutic approaches for choles-terol disorders and hypertension are described in ATP II and JNC VI, respectively.29,30In over-weight patients, control of cardiovascular risk factors deserves the same emphasis as weightloss therapy. Reduction of risk factors will reduce the risk for CVD, whether or not weight lossefforts are successful.
  24. 24. 16Treatment Algorithm*YesYesNoPatient encounter56Hx of ≥ 25 BMI?BMI measured inpast 2 years?BMI ≥ 25 OR waistcircumference > 35in (88 cm) (F) > 40 in(102 cm) (M)Assess risk factorsNoHx BMI ≥ 25?Brief reinforcement/educate on weightmanagementPeriodic weight, BMI, andwaist circumference checkAdvise to maintainweight/address otherrisk factorsFigure 4.• Measure weight,height, and waistcircumference• Calculate BMI1415 1316YesEach step (designated by a box) in this process is reviewed inthis section and expanded upon in subsequent sections.High Risk Waist CircumferenceMen >40 in (>102 cm)Women >35 in (>88cm)BMI =weight (kg)height squared (m2)If pounds and inchesare used:BMI =weight (pounds) x 703height squared (inches2)Calculate BMI as follows:1234
  25. 25. 17Does patient wantto lose weight?Progressbeing made/goalachieved?YesYesYes NoNoNoClinician and patientdevise goals andtreatment strategyfor weight loss and riskfactor controlMaintenance counseling:• Dietary therapy• Behavior therapy• Physical activityAssess reasons forfailure to lose weight128910117* This algorithm applies only to the assessment for overweight and obesity and sub-sequent decisions based on that assessment. It does not reflect any initial overallassessment for other cardiovascular risk factors that are indicated.ExaminationTreatmentBMI ≥ 30 OR{[BMI 25 to 29.9 ORwaist circumference> 35 in (F) > 40 in(M)] AND ≥ 2 riskfactors}
  26. 26. 18Patient encounterAny interaction between ahealth care practitioner (generallya physician, nurse practitioner, orphysician’s assistant) and a patientthat provides the opportunity toassess a patient’s weight statusand provide advice, counseling,or treatment.History of overweightor recorded BMI ≥ 25Seek to determine whether thepatient has ever been overweight.A simple question such as “Haveyou ever been overweight?” mayaccomplish this goal. Questionsdirected toward weight history,dietary habits, physical activities,and medications may provide usefulinformation about the origins ofobesity in particular patients.BMI measuredin past 2 yearsFor those who have not beenoverweight, a 2-year interval isappropriate for the reassessmentof BMI. Although this timespan isnot evidence-based, it is a reason-able compromise between theneed to identify weight gain atan early stage and the need tolimit the time, effort, and costof repeated measurements.Measure weight,height, waist circumference;calculate BMIWeight must be measured so BMIcan be calculated. Most charts arebased on weights obtained withthe patient wearing undergarmentsand no shoes.BMI ≥ 25 ORwaist circumference > 35 in(88 cm) (women) or > 40 in(102 cm) (men)These cutoff values divideoverweight from normal weightand are consistent with othernational and internationalguidelines. The relationshipbetween weight and mortality isJ-shaped, and evidence suggeststhat the right side of the “J” beginsto rise at a BMI of 25. Waistcircumference is incorporated asan “or” factor because somepatients with a BMI lower than25 will have a disproportionateamount of abdominal fat, whichincreases their cardiovascular riskdespite their low BMI (see pages9–10). These abdominalcircumference values are notnecessary for patients with aBMI ≥ 35 kg/m2.Assess risk factorsRisk assessment for CVD anddiabetes in a person with evidentobesity will include specialconsiderations for the medicalhistory, physical examination, andlaboratory examination. Detectionof existing CVD or end-organdamage presents the greatesturgency. Because the major risk ofobesity is indirect (obesity elicits oraggravates hypertension, dyslipi-demias, and type 2 diabetes; eachof these leads to cardiovascularcomplications), the managementof obesity should be implementedin the context of these other riskfactors. Although there is no directevidence that addressing risk factorsincreases weight loss, treating therisk factors through weight loss isa recommended strategy. The riskfactors that should be considered areprovided on pages 11–13. A nutri-tion assessment will also help toassess the diet and physical activityhabits of overweight patients.BMI ≥ 30 OR ([BMI 25 to29.9 OR waist circumference> 35 in (88 cm) (women) or> 40 in (102 cm) (men)]AND ≥ 2 risk factors)The panel recommends that allpatients who meet these criteriashould attempt to lose weight.However, it is important to ask thepatient whether or not he or shewants to lose weight. Those witha BMI between 25 and 29.9 kg/m2and who have one or no risk factorsshould work on maintaining theircurrent weight rather than embarkon a weight reduction program.The panel recognizes that thedecision to lose weight must bemade in the context of other riskfactors (e.g., quitting smoking ismore important than losing weight)and patient preferences.1346725Each step (designated by a box) in the treatment algorithm isreviewed in this section and expanded upon in subsequent sections.
  27. 27. 19Clinician and patientdevise goalsThe decision to lose weight mustbe made jointly between theclinician and patient. Patientinvolvement and investment iscrucial to success. The patient maychoose as a goal not to lose weightbut rather to prevent further weightgain. As an initial goal for weightloss, the panel recommends the lossof 10 percent of baseline weight ata rate of 1 to 2 pounds per weekand the establishment of an energydeficit of 500 to 1,000 kcal/ day(see page 23). For individuals whoare overweight, a deficit of 300 to500 kcal/day may be more appro-priate, providing a weight loss ofabout 0.5 pounds per week. Also,there is evidence that an average of8 percent of body weight can belost over 6 months. Since thisobserved average weight lossincludes people who do not loseweight, an individual goal of 10percent is reasonable. After6 months, most patients will equili-brate (caloric intake balancingenergy expenditure); thus, theywill require an adjustment of theirenergy balance if they are to losemore weight (see page 24).The three major components ofweight loss therapy are dietary ther-apy, increased physical activity, andbehavior therapy (see pages 26 to34). These lifestyle therapies shouldbe attempted for at least 6months before consideringpharmacotherapy. In addition,pharmacotherapy should beconsidered as an adjunct tolifestyle therapy for patientswith a BMI 30 kg/m2 and who haveno concomitant obesity-related riskfactors or diseases. Pharmaco-therapy may also be considered forpatients with a BMI 27 kg/m2 andwho have concomitant obesity-related risk factors or diseases. Therisk factors or diseases consideredimportant enough to warrantpharmacotherapy at a BMI of 27to 29.9 kg/m2 are hypertension,dyslipidemia, CHD, type 2 diabetes,and sleep apnea.Two drugs approved for weight lossby the FDA for long-term use aresibutramine and orlistat. However,sibutramine should not be used inpatients with a history of hyperten-sion, CHD, congestive heart failure,arrhythmias, or stroke. Certainpatients may be candidates forweight loss surgery.Each component of weight losstherapy should be introduced tothe patient briefly. The selectionof weight loss methods should bemade in the context of patient pref-erences, analysis of failed attempts,and consideration of availableresources.Progress beingmade/goal achievedDuring the acute weight lossperiod and at the 6-month and1-year followup visits, patientsshould be weighed, their BMIshould be calculated, and theirprogress should be assessed. If atany time it appears that the programis failing, a reassessment shouldtake place to determine the reasons(see Box 10). If pharmacotherapyis used, appropriate monitoring forside effects is recommended (seepages 35–37). If a patient canachieve the recommended 10-per-cent reduction in body weightwithin 6 months to 1 year, thischange in weight can be consideredgood progress. The patient canthen enter the phase of weightmaintenance and long-termmonitoring. It is important for thepractitioner to recognize that somepersons are more apt to lose or gainweight on a given regimen; thisphenomenon cannot always beattributed to the degree of compli-ance. However, if significantobesity persists and the obesity-associated risk factors remain, aneffort should be made to reinstituteweight loss therapy to achieve fur-ther weight reduction. Once the limitof weight loss has been reached, thepractitioner is responsible for long-term monitoring of risk factors andfor encouraging the patient to main-tain the level of weight reduction.8 9
  28. 28. Assess reasons for failureto lose weightIf a patient fails to achieve the rec-ommended 10-percent reduction inbody weight within 6 months or1 year, a reevaluation is required. Acritical question to consider iswhether the patient’s level of motiva-tion is high enough to continue clini-cal therapy. If motivation is high,revise goals and strategies (seeBox 8). If motivation is not high,clinical therapy should be discontin-ued, but the patient should beencouraged to embark on efforts tolose weight or to avoid furtherweight gain. Even if weight losstherapy is stopped, risk factor man-agement must be continued. Failureto achieve weight loss should promptthe practitioner to investigate the fol-lowing: (1) energy intake (i.e.,dietary recall including alcoholintake and daily intake logs),(2) energy expenditure (physicalactivity diary), (3) attendance at psy-chological/behavioral counseling ses-sions, (4) recent negative life events,(5) family and societal pressures,and (6) evidence of detrimental psy-chiatric problems (e.g., depression,binge eating disorder). If attemptsto lose weight have failed, and theBMI is ≥ 40, or 35 to 39.9 withcomorbidities or significant reduc-tion in quality of life, surgical thera-py should be considered.Maintenance counselingEvidence suggests that more than 80percent of the individuals who loseweight will gradually regain it.Patients who continue to use weightmaintenance programs have a greaterchance of keeping weight off.Maintenance includes continued con-tact with the health care practitionerfor education, support, and medicalmonitoring (see page 24).Does the patient wantto lose weight?Patients who do not want to loseweight but who are overweight(BMI 25 to 29.9), without a highwaist circumference and with one orno cardiovascular risk factors, shouldbe counseled regarding the need tomaintain their weight at or below itspresent level. Patients who wish tolose weight should be guided accord-ing to Boxes 8 and 9. The justifica-tion of offering these overweightpatients the option of maintaining(rather than losing) weight is thattheir health risk, although higherthan that of persons with a BMI< 25, is only moderately increased(see page 11).Advise to maintainweight/address otherrisk factorsPatients who have a history ofoverweight and who are now at anappropriate body weight, and thosepatients who are overweight butnot obese and who wish to focus onmaintenance of their current weight,should be provided with counselingand advice so their weight does notincrease. An increase in weightincreases their health risk andshould be prevented. The clinicianshould actively promote preventionstrategies, including enhanced atten-tion to diet, physical activity, andbehavior therapy. See Box 6 foraddressing other risk factors; evenif weight loss cannot be addressed,other risk factors should be treated.History of BMI ≥ 25This box differentiates those whopresently are not overweight andnever have been from those with ahistory of overweight (see Box 2).Brief reinforcementThose who are not overweight andnever have been should be advised ofthe importance of staying in this cat-egory.Periodic weight, BMI,and waist circumference checkPatients should receive periodicmonitoring of their weight, BMI, andwaist circumference. Patients whoare not overweight or have no historyof overweight should be screened forweight gain every 2 years. Thistimespan is a reasonable compromisebetween the need to identify weightgain at an early stage and the need tolimit the time, effort, and cost ofrepeated measurements.10151211141613
  29. 29. 21Ready or Not:Predicting Weight LossPredicting a patient’s readinessfor weight loss and identifyingpotential variables associatedwith weight loss success is an impor-tant step in understanding the needsof patients. However, it may be easi-er said than done. Researchers havetried for years with some success toidentify predictors of weight loss.Such predictors would allow healthcare practitioners, before treatment,to identify individuals who have ahigh or low likelihood of success.Appropriate steps potentially couldbe taken to improve the chances ofpatients in the latter category. Amongbiological variables, initial bodyweight and resting metabolic rate(RMR) are both positively relatedto weight loss. Heavier individualstend to lose more weight than dolighter individuals, although thetwo groups tend to lose comparablepercentages of initial weight. Studieshave not found that weight cyclingis associated with a poorer treatmentoutcome. Behavioral predictors ofweight loss have proved to be lessconsistent. Depression, anxiety, orbinge eating may be associatedwith suboptimal weight loss, thoughfindings have been contradictory.Similarly, measures of readiness ormotivation to lose weight have gen-erally failed to predict outcome. Bycontrast, self-efficacy—a patient’sreport that she or he can performthe behaviors required for weightloss—is a modest but consistentpredictor of success. Several stud-ies have also suggested that posi-tive coping skills contribute toweight control.Exclusion FromWeight Loss TherapyPatients for whom weight losstherapy is not appropriate aremost pregnant or lactatingwomen, persons with a seriousuncontrolled psychiatric illnesssuch as a major depression, andpatients who have a variety ofserious illnesses and for whomcaloric restriction might exacer-bate the illness. Patients withactive substance abuse and thosewith a history of anorexianervosa or bulimia nervosa shouldbe referred for specialized care.Consider a patient’s readi-ness for weight loss andidentify potential variablesassociated with weight losssuccess.
  30. 30. 22Clinical experience suggests thathealth care practitioners brieflyconsider the following issues whenassessing an obese individual’sreadiness for weight loss:“Has the individual sought weightloss on his or her own initiative?”Weight loss efforts are unlikely tobe successful if patients feel thatthey have been forced into treatmentby family members, their employer,or their physician. Before initiatingtreatment, health care practitionersshould determine whether patientsrecognize the need and benefits ofweight reduction and want to loseweight.“What events have led the patientto seek weight loss now?”Responses to this question will pro-vide information about the patient’sweight loss motivation and goals. Inmost cases, individuals have beenobese for many years. Somethinghas happened to make them seekweight loss. The motivator differsfrom person to person.“What are the patient’s stresslevel and mood?” There may notbe a perfect time to lose weight,but some are better than others.Individuals who report higher-than-usual stress levels with work, familylife, or financial problems may notbe able to focus on weight control.In such cases, treatment may bedelayed until the stressor passes, thusincreasing the chances of success.Briefly assess the patient’s mood torule out major depression or othercomplications. Reports of poorsleep, a low mood, or lack of plea-sure in daily activities can be fol-lowed up to determine whetherintervention is needed: it is usuallybest to treat the mood disorderbefore undertaking weight reduction.“Does the individual have aneating disorder, in addition toobesity?” Approximately 20 per-cent to 30 percent of obese indi-viduals who seek weight reduc-tion at university clinics sufferfrom binge eating. This involveseating an unusually large amountof food and experiencing loss ofcontrol while overeating. Bingeeaters are distressed by theirovereating, which differentiatesthem from persons who reportthat they “just enjoy eating and eattoo much.” Ask patients whichmeals they typically eat and thetimes of consumption. Bingeeaters usually do not have a regu-lar meal plan; instead, they snackthroughout the day. Althoughsome of these individuals respondwell to weight reduction therapy,the greater the patient’s distress ordepression, or the more chaoticthe eating pattern, the more likelythe need for psychological ornutritional counseling.“Does the individual understandthe requirements of treatmentand believe that he or she canfulfill them?” Practitioner andpatient together should select acourse of treatment and identifythe changes in eating and activityhabits that the patient wishes tomake. It is important to selectactivities that patients believe theycan perform successfully. Patientsshould feel that they have thetime, desire, and skills to adhereto a program that you haveplanned together.“How much weight does thepatient expect to lose? Whatother benefits does he or sheanticipate?” Obese individualstypically want to lose 2 to 3 timesthe 8 to 15 percent often observedand are disappointed when they donot. Practitioners must help patientsunderstand that modest weightlosses frequently improve healthcomplications of obesity. Progressshould then be evaluated byachievement of these goals, whichmay include sleeping better, havingmore energy, reducing pain,and pursuing new hobbies orrediscovering old ones, particularlywhen weight loss slows andeventually stops.A Brief Behavioral Assessment
  31. 31. 23The initial goal of weight losstherapy for overweightpatients is a reduction inbody weight of about 10 percent. Ifthis target is achieved, considera-tion may be given to further weightloss. In general, patients will wishto lose more than 10 percent ofbody weight; they will need to becounseled about the appropriate-ness of this initial goal.35,36Furtherweight loss can be considered afterthis initial goal is achieved andmaintained for 6 months. The ratio-nale for the initial 10-percent goalis that a moderate weight loss ofthis magnitude can significantlydecrease the severity of obesity-associated risk factors. It is betterto maintain a moderate weight lossover a prolonged period than toregain weight from a markedweight loss. The latter is counter-productive in terms of time, cost,and self-esteem.Rate of Weight LossA reasonable time to achieve a10-percent reduction in body weightis 6 months of therapy. To achieve asignificant loss of weight, an energydeficit must be created and main-tained. Weight should be lost at arate of 1 to 2 pounds per week,based on a caloric deficit between500 and 1,000 kcal/day. After6 months, theoretically, this caloricdeficit should result in a loss ofbetween 26 and 52 pounds.However, the average weight lossactually observed over this time isbetween 20 and 25 pounds. A greaterrate of weight loss does not yield abetter result at the end of 1 year.37It is difficult for most patients tocontinue to lose weight after 6months because of changes in rest-ing metabolic rates and problemswith adherence to treatment strate-gies. Because energy requirementsdecrease as weight is decreased, dietand physical activity goals need tobe revised so that an energy deficitis created at the lower weight,allowing the patient to continue tolose weight. To achieve additionalweight loss, the patient must furtherManagement ofOverweight and ObesityGoals for Weight Lossand ManagementThe following are general goalsfor weight loss and management:Reduce body weightMaintain a lower body weightover the long termPrevent further weight gain(a minimum goal)A 10 percent reduction in body weight reducesdisease risk factors. Weight should be lost at arate of 1 to 2 pounds per week based on acalorie deficit of 500–1,000 kcal/day.
  32. 32. 24decrease calories and/or increasephysical activity. Many studies showthat rapid weight reduction is almostalways followed by gain of thelost weight. Moreover, with rapidweight reduction, there is anincreased risk for gallstones and,possibly, electrolyte abnormalities.Weight Maintenance at aLower WeightOnce the goals of weight loss havebeen successfully achieved, mainte-nance of a lower body weightbecomes the major challenge. In thepast, obtaining the goal of weightloss was considered the end ofweight loss therapy. Unfortunately,once patients are dismissed fromclinical therapy, they frequentlyregain the lost weight.After 6 months of weight loss, therate at which the weight is lostusually declines, then plateaus.The primary care practitioner andpatient should recognize that, at thispoint, weight maintenance, the sec-ond phase of the weight loss effort,should take priority. Successfulweight maintenance is defined asa regain of weight that is less than6.6 pounds (3 kg) in 2 years anda sustained reduction in waistcircumference of at least 1.6 inches(4 cm). If a patient wishes to losemore weight after a period ofweight maintenance, the procedurefor weight loss, outlined above,can be repeated.After a patient has achieved thetargeted weight loss, the combinedmodalities of therapy (dietary thera-py, physical activity, and behaviortherapy) must be continued indefi-nitely; otherwise, excess weightwill likely be regained. Numerousstrategies are available for motivat-ing the patient; all of these requirethat the practitioner continue tocommunicate frequently with thepatient. Long-term monitoring andencouragement can be accom-plished in several ways: by regularclinic visits, at group meetings, orvia telephone or e-mail. The longerthe weight maintenance phasecan be sustained, the better theprospects for long-term success inweight reduction. Drug therapywith either of the two FDA-approved drugs for weight lossmay also be helpful during theweight maintenance phase.Long-term monitoring andencouragement to maintainweight loss requires regularclinic visits, group meetings,or encouragement viatelephone or e-mail.
  33. 33. 25Weight Management TechniquesEffective weight controlinvolves multiple tech-niques and strategiesincluding dietary therapy,physical activity, behaviortherapy, pharmacotherapy, andsurgery as well as combinations ofthese strategies. Relevant treatmentstrategies can also be used to fosterlong-term weight control and preven-tion of weight gain.Some strategies such as modifyingdietary intake and physical activitycan also impact on obesity-relatedcomorbidities or risk factors. Sincethe diet recommended is a low calo-rie Step-1 diet, it not only modifiescalorie intake but also reduces satu-rated fat, total fat, and cholesterolintake in order to help lower highblood cholesterol levels. The diet alsoincludes the current recommenda-tions for sodium, calcium and fiberintakes. Increased physical activity isnot only important for weight lossand weight loss maintenance but alsoimpacts on other comorbidities andrisk factors such as high blood pres-sure, and high blood cholesterol lev-els. Reducing body weight in over-weight and obese patients not onlyhelps reduce the risk of these comor-bidities from developing but alsohelps in their management.Weight management techniques needto take into account the needs of indi-vidual patients so they should be cul-turally sensitive and incorporate thepatient’s perspectives and characteris-tics. Treatment of overweight andobesity is to be taken seriously sinceit involves treating an individual’sdisease over the long term as well asmaking modifications to a way of lifefor entire families.Table 3 illustrates the therapiesappropriate for use at different BMIlevels taking into account theexistence of other comorbiditiesor risk factors.Table 3A Guide to Selecting TreatmentBMI categoryTreatment 25–26.9 27–29.9 30-34.9 35–39.9 ≥ 40Diet, physical activity, With With + + +and behavior therapy comorbidities comorbiditiesPharmacotherapy With + + +comorbiditiesSurgery Withc o m o r b i d i t i e sPrevention of weight gain with lifestyle therapy is indicated in any patient with a BMI ≥ 25 kg/m2,even without comorbidities, while weight loss is not necessarily recommended for those with a BMIof 25–29.9 kg/m2 or a high waist circumference, unless they have two or more comorbidities.Combined therapy with a low-calorie diet (LCD), increased physical activity, and behavior therapyprovide the most successful intervention for weight loss and weight maintenance.Consider pharmacotherapy only if a patient has not lost 1 pound per week after 6 months ofcombined lifestyle therapy.The + represents the use of indicated treatment regardless of comorbidities.
  34. 34. 26In the majority of overweight andobese patients, adjustment of thediet will be required to reducecaloric intake. Dietary therapyincludes instructing patients in themodification of their diets toachieve a decrease in caloric intake.A diet that is individually plannedto help create a deficit of 500 to1,000 kcal/day should be an integralpart of any program aimed atachieving a weight loss of 1 to2 pounds per week. A key elementof the current recommendation isthe use of a moderate reduction incaloric intake, which is designed toachieve a slow, but progressive,weight loss. Ideally, caloric intakeshould be reduced only to the levelthat is required to maintain weightat a desired level. If this level ofcaloric intake is achieved, excessweight will gradually decrease. Inpractice, somewhat greater caloricdeficits are used in the period ofactive weight loss, but diets with avery low-calorie content are to beavoided. Finally, the compositionof the diet should be modifiedto minimize other cardiovascularrisk factors.The centerpiece of dietary therapyfor weight loss in overweight orobese patients is a low calorie diet(LCD). This diet is different from avery low calorie diet (VLCD) (lessthan 800 kcal/day). The recom-mended LCD in this guide, i.e., theStep I Diet, also contains the nutri-ent composition that will decreaseother risk factors such as high bloodcholesterol and hypertension. Thecomposition of the diet is presentedin Table 4. In general, diets contain-ing 1,000 to 1,200 kcal/day shouldbe selected for most women; a dietbetween 1,200 kcal/day and 1,600kcal/day should be chosen formen and may be appropriate forwomen who weigh 165 pounds ormore, or who exercise regularly.If the patient can stick with the1,600 kcal/day diet but does notlose weight you may want to try the1,200 kcal/day diet. If a patienton either diet is hungry, you maywant to increase the calories by100 to 200 per day.VLCDs should not be usedroutinely for weight loss therapybecause they require special moni-toring and supplementation.50VLCDs are used only in very limit-ed circumstances by specializedpractitioners experienced in theiruse. Moreover, clinical trials showthat LCDs are as effective asVLCDs in producing weight lossafter 1 year.37Successful weight reduction byLCDs is more likely to occur whenconsideration is given to a patient’sfood preferences in tailoring aparticular diet. Care should betaken to ensure that all of therecommended dietary allowancesare met; this may require the useof a dietary or vitamin supplement.Dietary education is necessaryto assist in the adjustment to aLCD. Educational efforts shouldpay particular attention to thefollowing topics:Energy value of different foods.Food composition—fats,carbohydrates (including dietaryfiber), and proteins.Evaluation of nutrition labels todetermine caloric content and foodcomposition.New habits of purchasing—givepreference to low-calorie foods.Food preparation—avoid addinghigh-calorie ingredients duringcooking (e.g., fats and oils).Avoiding overconsumption ofhigh-calorie foods (both high-fatand high-carbohydrate foods).Adequate water intake.Reduction of portion sizes.Limiting alcohol consumption.Dietary TherapyLow calorie diet (LCD)1,000 to 1,200 kcal/dayfor most women1,200 to 1,600 kcal/dayshould be chosen for menSee Appendices B-H for dietsand information on physicalactivity that you can usewith your patients.
  35. 35. 27Table 4Low-Calorie Step I DietNutrient Recommended IntakeCalories1Approximately 500 to 1,000 kcal/day reduction from usual intakeTotal fat230 percent or less of total caloriesSaturated fatty acids38 to 10 percent of total caloriesMonounsaturated fatty acids Up to 15 percent of total caloriesPolyunsaturated fatty acids Up to 10 percent of total caloriesCholesterol3<300 mg/dayProtein4Approximately 15 percent of total caloriesCarbohydrate555 percent or more of total caloriesSodium chloride No more than 100 mmol/day (approximately 2.4 g of sodium orapproximately 6 g of sodium chloride)Calcium61,000 to 1,500 mg/dayFiber520 to 30 g/day1. A reduction in calories of 500 to 1,000 kcal/day will help achieve a weight loss of 1 to 2 pounds/week.Alcohol provides unneeded calories and displaces more nutritious foods. Alcohol consumption not onlyincreases the number of calories in a diet but has been associated with obesity in epidemiologic studies38-41as well as in experimental studies.42-45The impact of alcohol calories on a person’s overall caloric intakeneeds to be assessed and appropriately controlled.2. Fat-modified foods may provide a helpful strategy for lowering total fat intake but will only be effective if theyare also low in calories and if there is no compensation by calories from other foods.3. Patients with high blood cholesterol levels may need to use the Step II diet to achieve further reductions inLDL-cholesterol levels; in the Step II diet, saturated fats are reduced to less than 7 percent of total calories,and cholesterol levels to less than 200 mg/day. All of the other nutrients are the same as in Step I.4. Protein should be derived from plant sources and lean sources of animal protein.5. Complex carbohydrates from different vegetables, fruits, and whole grains are good sources of vitamins,minerals, and fiber. A diet rich in soluble fiber, including oat bran, legumes, barley, and most fruits andvegetables, may be effective in reducing blood cholesterol levels. A diet high in all types of fiber may alsoaid in weight management by promoting satiety at lower levels of calorie and fat intake. Some authoritiesrecommend 20 to 30 grams of fiber daily, with an upper limit of 35 grams.46-486. During weight loss, attention should be given to maintaining an adequate intake of vitamins and minerals. Maintenanceof the recommended calcium intake of 1,000 to 1,500 mg/day is especially important for women who may be at risk ofosteoporosis.49
  36. 36. 28Physical activity should be anintegral part of weight losstherapy and weight mainte-nance. Initially, moderate levels ofphysical activity for 30 to 45 min-utes, 3 to 5 days per week, shouldbe encouraged.An increase in physical activity is animportant component of weight losstherapy,31although it will not lead toa substantially greater weight lossthan diet alone over 6 months.51Most weight loss occurs because ofdecreased caloric intake. Sustainedphysical activity is most helpful inthe prevention of weight regain.52,53In addition, physical activity is bene-ficial for reducing risks for cardio-vascular disease and type 2 diabetes,beyond that produced by weightreduction alone. Many people livesedentary lives, have little trainingor skills in physical activity, and aredifficult to motivate toward increas-ing their activity. For these reasons,starting a physical activity regimenmay require supervision for somepeople. The need to avoid injury dur-ing physical activity is a high priori-ty. Extremely obese persons mayneed to start with simple exercisesthat can be intensified gradually. Thepractitioner must decide whetherexercise testing for cardiopulmonarydisease is needed before embarkingon a new physical activity regimen.This decision should be basedon a patient’s age, symptoms, andconcomitant risk factors.For most obese patients, physicalactivity should be initiated slowly,and the intensity should beincreased gradually. Initial activitiesmay be increasing small tasks ofdaily living such as taking the stairsor walking or swimming at a slowpace. With time, depending onprogress, the amount of weight lost,and functional capacity, the patientmay engage in more strenuousactivities. Some of these includefitness walking, cycling, rowing,cross-country skiing, aerobic danc-ing, and jumping rope. Jogging pro-vides a high-intensity aerobic exer-cise, but it can lead to orthopedicinjury. If jogging is desired, thepatient’s ability to do this must firstbe assessed. The availability of asafe environment for the jogger isalso a necessity. Competitive sports,such as tennis and volleyball, canprovide an enjoyable form of physi-cal activity for many, but again,care must be taken to avoid injury,especially in older people.As the examples listed in Table 5show, a moderate amount of physi-cal activity can be achieved in avariety of ways. People can selectactivities that they enjoy and thatfit into their daily lives. Becauseamounts of activity are functions ofduration, intensity, and frequency,the same amounts of activity canbe obtained in longer sessions ofmoderately intense activities (suchas brisk walking) as in shorter ses-sions of more strenuous activities(such as running).A regimen of daily walking is anattractive form of physical activityfor many people, particularly thosewho are overweight or obese. Thepatient can start by walking 10 min-utes, 3 days a week, and can buildto 30 to 45 minutes of more intensewalking at least 3 days a week andincrease to most, if not all, days.52,53With this regimen, an additionalPhysical ActivityAll adults should seta long-term goal toaccumulate at least30 minutes or moreof moderate-intensityphysical activity onmost, and preferablyall, days of the week.
  37. 37. 29100 to 200 kcal/day of physicalactivity can be expended. Caloricexpenditure will vary depending onthe individual’s body weight andthe intensity of the activity.This regimen can be adapted toother forms of physical activity,but walking is particularly attractivebecause of its safety and acces-sibility. With time, a larger weeklyvolume of physical activity can beperformed that would normallycause a greater weight loss if itwere not compensated by a highercaloric intake.Reducing sedentary time, i.e.,time spent watching television orplaying video games, is anotherapproach to increasing activity.Patients should be encouraged tobuild physical activities into eachday. Examples include leavingpublic transportation one stopbefore the usual one, parking far-ther than usual from work or shop-ping, and walking up stairs insteadof taking elevators or escalators.New forms of physical activityshould be suggested (e.g., garden-ing, walking a dog daily, or newathletic activities). Engaging inphysical activity can be facilitatedby identifying a safe area to per-form the activity (e.g., communityparks, gyms, pools, and healthclubs). However, when thesesites are not available, an areaof the home can be identified andperhaps outfitted with equipmentsuch as a stationary bicycle or atreadmill. Health care profession-als should encourage patients toplan and schedule physical activity1 week in advance, budget thetime necessary to do it, and docu-ment their physical activity bykeeping a diary and recording theduration and intensity of exercise.The following are examples ofactivities at different levels ofintensity. A moderate amount ofExamples of Moderate Amounts of Physical Activity*Common Chores Sporting ActivitiesWashing and waxing a car for 45–60 minutes Playing volleyball for 45–60 minutesWashing windows or floors for 45–60 minutes Playing touch football for 45 minutesGardening for 30–45 minutes Walking 13/4 miles in 35 minutes (20 min/mile)Wheeling self in wheelchair for 30–40 minutes Basketball (shooting baskets) for 30 minutesPushing a stroller 11/2 miles in 30 minutes Bicycling 5 miles in 30 minutesRaking leaves for 30 minutes Dancing fast (social) for 30 minutesWalking 2 miles in 30 minutes (15 min/mile) Water aerobics for 30 minutesShoveling snow for 15 minutes Swimming laps for 20 minutesStairwalking for 15 minutes Basketball (playing a game) for 15–20 minutesJumping rope for 15 minutesRunning 11/2 miles in 15 minutes (15 min/mile)* A moderate amount of physical activity is roughly equivalent to physical activity that uses approximately150 calories of energy per day, or 1,000 calories per week.† Some activities can be performed at various intensities; the suggested durations correspond to expectedintensity of effort.Table 5MoreVigorous,Less TimeLessVigorous,More Time†
  38. 38. 30physical activity is roughly equiv-alent to physical activity that usesapproximately 150 calories ofenergy per day, or 1,000 caloriesper week.For the beginner, or someone wholeads a very sedentary lifestyle,very light activity would includeincreased standing activities, roompainting, pushing a wheelchair,yard work, ironing, cooking, andplaying a musical instrument.Light activity would include slowwalking (24 min/mile), garagework, carpentry, house cleaning,child care, golf, sailing, and recre-ational table tennis.Moderate activity would includewalking a 15-minute mile, weed-ing and hoeing a garden, carryinga load, cycling, skiing, tennis, anddancing.High activity would includejogging a mile in 10 minutes,walking with a load uphill, treefelling, heavy manual digging,basketball, climbing, and soccer.Other key activities wouldinclude flexibility exercises toattain full range of joint motion,strength or resistance exercises,and aerobic conditioning.Behavior therapy providesmethods for overcomingbarriers to compliance withdietary therapy and/or increasedphysical activity, and these meth-ods are important components ofweight loss treatment. The follow-ing approach is designed to assistthe caregiver in delivering behav-ior therapy. The importance ofindividualizing behavioral strate-gies to the needs of the patientmust be emphasized for behaviortherapy, as it was for diet andexercise strategies.54In addition, the practitioner mustassess the patient’s motivation toenter weight loss therapy and thepatient’s readiness to implementthe plan. Then the practitioner cantake appropriate steps to motivatethe patient for treatment.Making the Most ofthe Patient VisitConsider Attitudes, Beliefs,and Histories.In the patient-provider interaction,individual histories, attitudes, andbeliefs may affect both parties.The diagnosis of obesity is rarelynew or news for the patient.Except for patients with veryrecent weight gain, the patientbrings into the consulting room ahistory of dealing with a frustrat-ing, troubling, and visible prob-lem. Obese people are often therecipients of scorn and discrimina-tion from strangers and, some-times, hurtful comments fromprevious health care professionals.The patient with obesity may beunderstandably defensive aboutthe problem.Be careful to communicatea nonjudgmental attitude thatdistinguishes between theweight problem and the patientwith the problem. Ask aboutthe patient’s weight history andhow obesity has affected his orher life. Express your concernsabout the health risks associatedwith obesity, and how obesity isaffecting the patient.Similarly, most providers have hadsome frustrating experiences indealing with patients with weightproblems. Appropriate respect forthe difficulty of long-term weightcontrol may mutate into a reflex-ive sense of futility. When effortsto help patients lose weight areunsuccessful, the provider may bedisappointed and may blame thepatient for the failure, seeingobese people as uniquely noncom-pliant and difficult. Providers toomay feel some antifat prejudice.Objectively examine your ownattitudes and beliefs about obe-sity and obese people.Remember, obesity is a chronicdisease, like diabetes or hyper-tension. In a sense, patients arestruggling against their ownbody’s coordinated effort toBehavior Therapy

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